Acknowledgements Rebalancing long-term services and supports This - - PDF document

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March 29, 2019

• Dr. Kelsey Simons

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Addressing Social Isolation and Suicide Risk Among Older Veterans Who Return to the Community from VA Nursing Homes

Kelsey Simons, PhD, LMSW Researcher VISN 2 Center of Excellence for Suicide Prevention Canandaigua VAMC Clinical Assistant Professor, University of Rochester Medical Center, Department of Psychiatry

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Co-Investigators

Nathan A. Kerr, M.A. Postdoctoral Fellow Uniformed Services University of the Health Sciences, Department of Medical and Clinical Psychology Whitney L. Mills, PhD Investigator, Center for Innovation in Long-Term Services and Supports Providence VA Medical Center Assistant Professor of Health Services, Policy and Practice (Research) School of Public Health, Brown University

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Acknowledgements

• This work was supported with resources and

use of facilities at the VISN 2 Center of Excellence for Suicide Prevention at Canandaigua, VAMC. The contents do not represent the views of the US Department of Veterans Affairs or the United States Government.

• The researchers have no conflict of interests

to report.

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Policy Context (Macro Environment)

“Rebalancing” long-term services and supports

• More community-based options for receiving care
• Limit use of institutional care (e.g., nursing homes)
• Community Living Centers (CLCs)
• Shift towards more discharges
• Short-stay placements (≤ 90 days)
• Majority (61%) of all stays
• 74% discharge to community
• Long-stay (>90 days)
• 16% of stays
• 60% discharge to community
• Hospice stays
• Only type that has increased over time
• 22.5% of stays as of 2011

Thomas KS, Cote D, Makineni R, et al.. (2018)

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Retrospective chart review– outpatient visits, inpatient and CLC admissions

• VA patients ≥ 65 (2005 – 2013)

Overall (2013):

• 14% ≥ 65 with confirmed mental

illness (+57% from 2005) Setting specific (2013):

• 28% of non–mental health
• utpatient encounters
• 39% of non–mental health inpatient

hospitalizations

• 49% of nursing home stays

Take away:

• Increased screening
• Integration of mental health care
• Greater utilization of health services

Wiechers, I. R., Karel, M. J., Hoff, R., & Karlin, B. E. (2015). Growing Use of Mental and General Health Care Services Among Older Veterans With Mental Illness. Psychiatric Services, 66(11), 1242-1244.

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Semi-structured interviews:

• Frontline staff in eight CLCs
• 12 – 16 interviews per CLC

Focus:

• Experiences with culture change
• Resident-centered, homelike environments
• Processes/ practices related to discharge

Key findings:

• CLCs  “a latent function of connecting Veterans socially.” (p. 323)
• Staff and Veterans also develop bonds
• May encourage extended stays:

“we’ve seen patients even kind of sabotage their care in

• rder to stay longer because, and you know, and it just tells me that

their home environment probably is so lonely” (physician)

Harrison et al. (2017)

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SLIDE 2

March 29, 2019

• Dr. Kelsey Simons

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• Analysis of all live discharges (2002 – 2008)
• Compared with age and gender-matched

group of VA patients:

• Following CLC discharge:
• Suicide risk 2.4 times as high overall
• Particularly high in the first three

weeks post discharge.

• Take away: “This suggests the importance of

active outreach efforts and attention to residents’ adjustment to living in community settings after discharge.” (p. 2265)

McCarthy JF, Szymanski BR, Karlin BE, Katz IR. Suicide mortality following nursing home discharge in the Department of Veterans Affairs health system. Am J Public

• Health. 2013;103(12):2261-2266.

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Veterans in Transition Study

• Describe the experience of transitioning from a

VA CLC to the community.

– How well do Veterans adjust to a return to the community?

• Compare pre and post-discharge

– Expectations for activities vs. actual routines

• Return to usual activities or a change in routines

– The social environment

• Social connectedness versus disconnectedness
• Housing post-discharge

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Methods

Sites:

• Two VAMCs in Upstate NY (2015 – 2017)
• ≥ 50 years of age
• Planned discharge to the community
• Able to provide informed consent

Semi-structured interviews:

• 21 Veterans pre-discharge (CLC)
• 18 post (private homes)
• 14 caregivers

PHQ-9:

• Post-discharge

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Veteran Interviews

Pre-discharge  First, what can you tell me about your stay here?

• What’s been good about being here or perhaps not so good

about being here?  Do you have particular hopes or expectations for the future?

• Do you think you will go back to your old routines and activities
• r maybe start new ones?

 Do you feel ready to leave? Why or why not?

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Post-discharge  So how are you doing now that you are home?

• Is it going as well as you had hoped?
• What’s been good about it? Or, what’s perhaps been not

so good?  How do you spend your time these days?

• Have you gone back to your old routines and activities or

started any new ones?  Do you think you have enough people to talk to?

• Do you ever feel lonely? Tell me about that.

 How are you feeling about your current living situation?

Veteran Interviews

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Stage 1:

• Two analysts hand-coded each verbatim transcript
• Team met weekly
• Coding decisions/resolve discrepancies
• Development of separate codebooks
• Veterans and caregivers

Stage 2:

• Coded transcripts entered into NVivo
• Thematic analysis performed in NVivo

Thematic analysis

Guest G, MacQueen, K.M, Namey, E.E. . Applied Thematic

• Analysis. Thousand Oaks, CA: SAGE; 2012.

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SLIDE 3

March 29, 2019

• Dr. Kelsey Simons

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Demographic and Background Characteristics

N (or Mean) %(or SD) Veterans (n=21) Age 70.8 7.3 (SD) Male 20 95.2% White 18 85.7% Rural 14 66% Vietnam era 18 85.7% Combat Veteran 9 42.9% Living with spouse 9 42.9% Living alone 7 33% Multigenerational 4 19% Caregivers (n = 14) Female 14 100% Age 66.4 6.4 (SD)

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Post-Discharge Depressive Symptoms

PHQ-9 (N = 18)

• Mean = 4.89 (SD = 6.07)
• Range = 0 – 23
• Minimal = 12
• Mild: n = 3
• Moderate: n = 1
• Moderately severe: n = 1
• Severe: n = 1

– Positive for ideation: n = 1

Kroenke, Spitzer & Williams (2001)

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Expectations for Routines/ Activities (Pre)

Many Veterans expressed a wish to be more active. For example, with their dogs:

• ”I want to do some of the things that we did, take walks, ride

in the car. She loves those things.”

• ”I just hope that, I can not walk the dog, but kind of play with

him.”

• ”If I can walk easier and better I’m going to be able to

exercise with her.” Or in general:

• ”…getting up and moving instead of sitting in the recliner.”
• ”I look forward to walking in the streets eventually.”
• ”I’ll be able to go back to working out, getting back in

shape again.”

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Actual Routines and Activities (Post)

After discharge, many were semi-homebound or engaged in solitary activities.

• ”I’ll sit upstairs and listen to music sometimes, but that’s

about it. I don’t stray too far from home.”

• ”I spend most of the day just sleeping, dozing off, you

know.”

• ”Oh, yeah, TV is on. And then I wait

for [spouse] to get home.”

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Actual Routines and Activities (Post)

Caregivers often reinforced this finding.

• ”that’s all he does because we’re not able to get out of the

house.”

• ”He still is just pretty stagnant as far as a lot of that

physical activity goes.”

• ”…then he comes out to lunch and back to the TV.

Then he comes out for dinner and then back to the TV.”

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Social Connectedness (Pre)

Many Veterans discussed enhanced connectedness with peers.

• ”I made friends here, and I talk to them about things that I

would never talk to anybody else about.”

• ”I have made some real, real close friends, people that

are my age or older, a few younger.”

• ”There would be three or four in here laughing and joking

and having fun. I enjoyed every bit of it.”

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SLIDE 4

March 29, 2019

• Dr. Kelsey Simons

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Social Connectedness (Pre)

Certain caregivers also mentioned this:

• ”…he met a lot of the guys that was in Vietnam where,

and they like, became like a little family there.”

• ”He loved having all those guys around… it was this

whole little frat boy thing going on.”

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Social Connectedness (Post)

Varied descriptions of social connectedness after discharge. For example, introverted or socially withdrawn:

• “I can talk to myself if I have any problems.”
• ”I’m an introvert. I don’t need a lot of people to talk to.”

Or, feeling lonely or disconnected:

• ”The lonely part would be just the camaraderie of another

male.”

• ”If I get to feel lonely, I usually call somebody, so it’s not as

bad.” Or, feeling connected:

• ”sometimes it’s nice to have—to feel lonely, but I haven’t felt

that yet.”

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Social Connectedness (Post)

Caregivers’ often provided more revealing descriptions. Disconnected:

• ”He doesn’t have any social life. He doesn’t do anything
• utside of being with me.”
• ”I’ve noticed, you know, with each hospitalization he’s gotten

like a turtle.”

• ”He’s very, very lonely down there.”

Connected:

• “He likes going out and about.

You know, he likes visiting friends.”

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Environmental Context (Post)

Home is usually a comfort.

• ”My dog. I got to see her more regularly than I did [at the

CLC].”

• ”the psychological boost of coming home…”
• ”…you feel more comfortable…”

Though home could be a source of stress.

• ”I’d like to see this house burnt to the ground…I hate the

thing.”

• ”I actually want to be closer—I want to be back in [City].”
• ”I got too much stuff. Too much stuff.”

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Discussion

Some Veterans reported symptoms of depression (PHQ-9)

• In certain cases, moderate to severe

Many discussed social connections in the CLC (Harrison et al.,

2017)

• Recovery of social function?

Post-discharge

• Social withdrawal/isolation and more solitary activities

Home environment

• A source of comfort
• A source of stress

Poor social connectedness/ low social integration

• Associated with suicide ideation in older Veterans

(Fanning & Pietrzak, 2013)

• Risk factor for suicide in adults 50+ (Duberstein et al., 2004)

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Implications for Clinical Care and Research

• Care transitions are a period of risk for suicide (McCarthy et al. 2013)
• Key opportunity for suicide prevention and intervention

research (Szanto et al., 2014)

• Isolation in older adults
• An overlooked clinical target
• Assess/ identify/ minimize barriers to social connection
• PROMIS social health tools (Hahn et al., 2011)
• http://www.healthmeasures.net/

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SLIDE 5

March 29, 2019

• Dr. Kelsey Simons

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What’s Next?

The Senior Connection:(U01CE001942, Conwell-PI)

• Senior Corps volunteers matched with socially isolated,

community dwelling older adults

• Friendly visiting, non-medical caregiving, and social

connection

• Volunteers sponsored, trained, and supervised by

Area Agency on Aging RCT (n = 369, 46% male) Significant reductions in suicide risk factors:

• feeling like a burden
• depressive symptoms
• anxiety

Van Orden et al. (2013); Pepin, Bruce, Sirey, Van Orden, & Conwell (2018)

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TSC-VA

Peer Companionship for Veterans Returning to the Community from VA Community Living Centers

• Resubmission VA RR&D: March 2019
• Will match older Veteran peer companions (Veterans

Corps) with Veterans discharging from CLCs Aim 1: Translate an existing, community-based peer companionship intervention (The Senior Connection) as an enhancement to care as usual transitions from VA CLCs (n = 10) Aim 2: Examine acceptability and feasibility of VA-TSC to inform a follow-up RCT (n = 24).

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Senior Corps Example

https://youtu.be/l403IKfCQ2M

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Comments? Questions? Kelsey.Simons@va.gov

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References

Duberstein PR, Conwell Y, Conner KR, Eberly S, Evinger JS, Caine ED. Poor social integration and suicide: fact or artifact? A case-control study. Psychological

• Medicine. 2004;34(7):1331-1337.

Fanning JR & Pietrzak RH. Suicidality among older male veterans in the United States: Results from the National Health and Resilience in Veterans Study. Journal of Psychiatric Research. 2013;47(11):1766-1775 Guest G, MacQueen, K.M, Namey, E.E. . Applied Thematic Analysis. Thousand Oaks, CA: SAGE; 2012. Hahn EA, Devellis RF, Bode RK, et al. Measuring social health in the patient-reported

• utcomes measurement information system (PROMIS): item bank development

and testing. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation. 2010;19(7):1035-1044. Harrison J, Tyler DA, Shield RR, et al. An Unintended Consequence of Culture Change in VA Community Living Centers. J Am Med Dir Assoc. 2017;18(4):320- 325. Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ‐9. Journal of General Internal Medicine, 16(9), 606-613. McCarthy JF, Szymanski BR, Karlin BE, Katz IR. Suicide mortality following nursing home discharge in the Department of Veterans Affairs health system. Am J Public Health. 2013;103(12):2261-2266.

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References

Pepin R, Bruce ML, Sirey JA, Van Orden KA, Conwell Y. Meet Me Where I Am: Expanding the Reach of Mental Health Services with Home and Community-Based Services. The American Journal of Geriatric

• Psychiatry. 2018;26(3):S15-S16

Szanto, K., Lenze, E. J., Waern, M., Duberstein, P., Bruce, M. L., Epstein- Lubow, G., & Conwell, Y. (2014). Research to reduce the suicide rate among older adults: methodology roadblocks and promising paradigms. Psychiatric Services, 64(6), 586-589. Thomas KS, Cote D, Makineni R, et al. Change in VA Community Living Centers 2004-2011: Shifting Long-Term Care to the Community. J Aging Soc Policy. 2018;30(2):93-108. Van Orden KA, Stone DM, Rowe J, McIntosh WL, Podgorski C, Conwell Y. The Senior Connection: Design and rationale of a randomized trial of peer companionship to reduce suicide risk in later life. Contemp Clin Trials. 2013. Wiechers, I. R., Karel, M. J., Hoff, R., & Karlin, B. E. (2015). Growing Use of Mental and General Health Care Services Among Older Veterans With Mental Illness. Psychiatric Services, 66(11), 1242-1244.

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